children rights ....pdf

ARTICLE
Children’s Rights,
Environmental Justice, and
Environmental Health Policy
in the United States
Mary L. Chesney, PhD, APRN, CPNP, FAAN, FAANP, &
Karen Duderstadt, PhD, RN, CPNP, FAAN
Environmentalists have forewarned that our planet is in peril
because of serious degradation and pollution of the earth’s land,
air, water, and food sources. Climate change is present and worsen-
ing at an alarming rate. Gaping disparities exist between high-
income and low-income countries and high-income and low-
income zip codes in the United States, resulting in marginalized
and vulnerable populations bearing the greatest burden from the ill
effects of pollution and environmental toxins. Infants and children
carry the greatest risk for pollution-related diseases and exposure
to chemical toxins as their bodies are rapidly developing. This
review article provides a historical overview of children’s rights to
protection from environmental health risks, effects of environmen-
tal injustice, and U.S. statutory and regulatory policies responsible
for protecting food, air, and water quality. The authors advocate
for policy and clinical strategies to support children’s health and the
right to environmental protection. J Pediatr Health Care. (2022) 36,
3−11
KEY WORDS
Child health, environment, environmental justice, pollution, air
quality, water quality, toxins
INTRODUCTION
The concept of planetary health represents awareness that
human existence and health are reliant on a thriving, sustain-
able ecosystem and responsible stewardship of the earth’s
natural resources and systems (Whitmee et al., 2015). For
decades, environmentalists have forewarned that our planet
and people are in peril because of serious degradation of the
earth’s land, air, water, and food sources. Pollution is now
responsible for 16% of deaths across the globe and ranks as
the greatest global environmental cause of premature death
and disease (Landrigan et al., 2018).
In 2016, 940,000 of the world’s children died because of
pollution. Two-thirds of those deaths occurred in young
children aged < 5 years (Landrigan et al., 2019). Because of
developmental windows of vulnerability, infants and young
children are at the greatest risk for pollution-related diseases
and conditions, even when exposed to relatively low doses
of pollutants (Landrigan et al., 2018). Respiratory and gas-
trointestinal illness because of polluted air and water account
for most deaths, but pollution also causes other types of
noncommunicable diseases that increase the risk for prema-
ture death (Landrigan et al., 2019).
The World Health Organization (2017) reports that bio-
logical, physical, and chemical environmental hazards are
responsible for 26% of all global deaths of children aged <
5 years. Because of environmental inequities, poor, marginal-
ized, and vulnerable populations bear the greatest burden
from the ill effects of pollution, with 92% of pollution-
related deaths occurring among low and middle-income
countries of the world (Landrigan et al., 2018). Pollution,
Mary Chesney, Clinical Professor, University of Minnesota School
of Nursing, Minneapolis, MN
Karen G. Duderstadt, Clinical Professor Emerita, Department of
Family Health Care Nursing, School of Nursing, University of
California San Francisco, San Francisco, CA.
Conﬂicts of interest: None to report.
Correspondence: Mary L. Chesney, PhD, APRN, CPNP, FAAN,
FAANP, University of Minnesota School of Nursing, 540 Weaver-
Densford Hall, 308 Harvard St. S.E., Minneapolis, MN 55447;
e-mail: chesn009@umn.edu.
J Pediatr Health Care. (2022) 36, 3-11
0891-5245/$36.00
Copyright © 2021 by the National Association of Pediatric Nurse
Practitioners. Published by Elsevier Inc. All rights reserved.
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environmental injustice, and poverty are deeply intercon-
nected and coexist in a reciprocal relationship. The effects of
poverty and environmental inequities are often dispropor-
tionately experienced by children (World Health Organiza-
tion, 2017). Children and their families who live in poverty
are more likely to experience environmental injustices, mak-
ing them more likely to be exposed to polluted air, water,
and food. As a result, low-income families experience more
disease, disability, or death, which further exacerbates pov-
erty by decreasing parents’ ability to work and provide for
their children (Landrigan et al., 2019).
Human-initiated environmental degradation contributes
to climate change and disruptions of the earth’s natural eco-
systems. Climate change is responsible for an increase in
floods, droughts, heatwaves, and elevated exposures to ultra-
violet radiation and pollutants (Whitmee et al., 2015). The
U.S. Centers for Disease Control and Prevention list eight
effects of climate change exposure: air pollution, changes in
vector etiology, increasing allergens, water quality impacts,
impact on food and water supply, environmental degrada-
tion, extreme heat, and severe weather events. These climate
change exposures pose increased risk for asthma, respiratory
allergens, and cardiovascular disease; heat-related illnesses
and deaths; vector-borne illnesses such as malaria, dengue,
and Lyme’s disease; diarrheal diseases such as cholera and
cryptosporidiosis; malnutrition; forced migration; and inju-
ries or death from severe weather events (Centers for Dis-
ease Control and Prevention, n.d.). Children and families
forced to migrate because of severe weather disasters,
extreme heat, or lack of adequate water or food sources face
an elevated risk for physical illness and psychological stress
(Centers for Disease Control and Prevention, n.d.; Goldha-
gen et al., 2020).
Researchers report a growing list of diseases and condi-
tions associated with climate change and children’s exposure
to pollution and environmental toxins. Infants and young
children exposed to polluted air face heightened risks of
lower respiratory infections (World Health Organization,
2017), lung damage, stunted lung growth, pneumonia,
asthma, and chronic obstructive lung disease (Gauderman
et al., 2015). Air, water, or food contaminated with heavy
metals such as lead (Budtz-Jørgensen, Bellinger, Lanphear,
Grandjean, & International Pooled Lead Study Investigators,
2013; World Health Organization, 2017), arsenic (Wasser-
man et al., 2007), or methylmercury (Grandjean, Satoh,
Murata, & Eto, 2010) pose heightened risk for neurodeve-
lopmental impairment and diminution of intelligence quo-
tient in children. Exposure to toxins such as polychlorinated
biphenyls (Budtz-Jørgensen et al., 2013) and the pesticide
chlorpyrifos (Grandjean & Landrigan, 2014) are associated
with neurodevelopmental impairment. A number of studies
associate exposure to poly- and perfluoroalkyl substances
with adverse immune disorders in children (Rapazzo, Coff-
man, & Hines, 2017; Sunderland et al., 2019).
Researchers have also identified at least 175 toxic chemi-
cals in the environment considered likely carcinogenic
(Washington State Department of Health, 2012).
Polybrominated biphenyls (PCBs), various pesticides and
herbicides (Piazza & Urbanetz, 2019), and poly- and per-
fluoroalkyl substances (Rapazzo et al., 2017) have been asso-
ciated with the development of various types of endocrine
and reproductive disorders. This substantial and growing
body of evidence underscores the inextricable link between
the health of our planet and child health.
This review article aims to provide a historical overview
of children’s rights, environmental justice, and environmen-
tal policy in the United States; describe the U.S. regulatory
agencies and laws responsible for protecting food, air, and
water quality; and provides advocacy strategies to support
children’s right to health and environmental protection.
Articles from 2011 to 2021 were included in this histori-
cal review and were extracted using the following search
databases: CINAHL, Medline, PubMed, and Web of Sci-
ence. Search words included “child health,” “environment,”
“environmental justice,” “environmental racism,” “pollu-
tion,” “air quality,” “water quality,” and “toxins.” In addition,
statutory and regulatory information was gleaned from U.S.
Congressional and federal agency Web sites and academic
environmental legal analysis sites.
CHILDREN’S RIGHTS
In 1989, leaders from around the world assembled to make a
historic commitment to protect and promote the rights of
the world’s children. They drafted and adopted an interna-
tional legal framework, the United Nations Convention on the
Rights of the Child, “. . .the most widely ratified human rights
treaty in history” (United Nations Children’s Fund [UNI-
CEF], n.d.a, para. 1). According to the treaty’s primary ten-
ets, children are individuals with human rights, and
childhood is a special, protected time, separate from adult-
hood, during which children should be allowed to grow,
develop, and thrive with dignity (UNICEF, n.d.a). The treaty
further lists four core principles (UNICEF, n.d.b):
1. Children should live free from discrimination.
2. For all actions concerning children, public and private
entities should consider the best interest of the child.
3. To the greatest possible extent, state parties are
obliged to ensure a child’s right to survival and devel-
opment.
4. Children have the right to freely express their views on
matters affecting them.
From an environmental justice perspective, Article 24 of
the treaty establishes children’s right to optimal health, health
care access, and “the provision of adequate nutritious foods
and clean drinking water, taking into consideration the dan-
gers and risks of environmental pollution” (United Nations
General Assembly, 1989).
In 1995, the Clinton administration signed the treaty, a
signal of the United States’s agreement with the treaty’s prin-
ciples. However, thus far, the United States. Senate has failed
to ratify the treaty by a required two-thirds vote (Attiah,
2014; UNICEF, n.d.b). Of the 196 participating country
4 Volume 36 Number 1 Journal of Pediatric Health CareÒ

signatories, the United States, South Sudan, and Somali
remain the only countries that have not ratified the treaty
(UNICEF, n.d.b). Chief arguments given for nonratification
in the United States involve concerns expressed by some
Senate members and conservative parent and family organi-
zations that the treaty may limit U.S. sovereignty and poten-
tially allow the United States government to leverage
“unlimited interference into family life” (Minasyan, 2018,
para. 4). Treaty proponents argue that countries that have
ratified the treaty have made significant progress in advanc-
ing policies and laws that improve children’s access to health
care, education, nutritious foods, and protection from
exploitation and violence (UNICEF, n.d.b). Despite these
advancements, environmental inequities and injustices per-
sist and pose threats to the survival of the world’s children.
ENVIRONMENTAL JUSTICE
Environmental justice is defined as “the fair treatment and
meaningful involvement of all people regardless of race,
color, national origin, or income, with respect to the devel-
opment, implementation, and enforcement of environmen-
tal laws, regulations, and policies” (Environmental
Protection Agency [EPA], 2021c, para. 1). Despite national
and global efforts to promote environmental justice, gaping
disparities exist between high-income and low-income coun-
tries and wealthy and poor citizens within countries. Millions
of children across the globe are denied their right to live in a
safe, clean environment (Goldhagen et al., 2020). In the
United States, disparities such as increased rates of low birth
weight, preterm births, and increased incidence of asthma
exist related to toxic environmental exposures in areas pre-
dominantly populated by persons of color or persons living
in poverty (Alexander Curie, 2017; Bailey, Feldman,
Bassett, 2021; Nardone et al., 2020).
Many children also bear the burden of environmental
racism. Environmental racism results in people of color
being more adversely impacted by environmental hazards
than higher-income and white populations. According to
Greenaction for Health and Environmental Justice (n.d.,
para. 6),
Environmental racism refers to the institutional rules, regulations,
policies or government and/or corporate decisions that deliberately
target certain communities for locally undesirable land uses and lax
enforcement of zoning and environmental laws, resulting in commu-
nities being disproportionately exposed to toxic and hazardous
waste based on race.
Few examples of U.S. government-sanctioned environ-
mental racism are as stark as the redlining policies developed
during the Great Depression era. The federal government
established the Home Owner’s Loan Corporation in 1933.
Home Owner’s Loan Corporation determined mortgage
worthiness on the basis of a zoning system that rated neigh-
borhoods in 239 cities from green grade A (best) to red
grade D (least desirable or hazardous) (Bailey et al., 2021;
Nardone et al., 2020). The term redlining has been used to
signify areas where, historically, residents were
predominantly persons of color. Redlining led to race-based,
government-condoned policies, such as neighborhood asso-
ciation covenants that prevented Blacks from purchasing
homes in certain neighborhoods.
During the past decade, researchers have examined
broad environmental disinvestments and increased exposure
to pollution and heat in previously designated redlined
neighborhoods (Namin, Xu, Zhou, Beyer, 2020; Nar-
done, Rudolph, Morello-Frosch, Casey, 2021). Redlined
neighborhoods often have limited green spaces with shade
and increased heat-retaining concrete structures such as
large concrete highway constructions and large commercial
buildings, which result in redlined areas being an average
2.6°C warmer (Nardone et al., 2021).
Median age-adjusted rates of emergency room visits for
asthma exacerbations were found to be 2.4 times higher for
children in previously redlined areas in eight California cities
(Nardone et al., 2020). Alexander and Currie (2017) noted
higher levels of outdoor and indoor air pollution in Black
zip codes in New Jersey, defined as zip codes in which most
children are Black. They found that all low birth weight chil-
dren had a higher incidence of asthma regardless of race if
they lived in a predominantly Black zip code, underscoring
the importance of residential segregation as a plausible
explanation for some racial health disparities (Alexander
Currie, 2017).
The location of coal power plants provides another
example of environmental injustice on the basis of low
income or race. Coal-fired power plants in the United
States tend to be disproportionately located in low-
income communities and communities of color (Wilson
et al., 2012). An estimated 6 million people live within
4.8 km of a coal-fired power plant, and 39% are people
of color. Proximity to coal-fired power plants has serious
health consequences, especially for pregnant women and
young children, because of the high level of toxins emit-
ted into the air and local water supply such as sulfur
dioxide, nitrous oxide, fine particulate matter, mercury,
arsenic, lead, and other heavy metals.
Sulfur dioxide is one of the primary pollutants produced
by burning coal which causes poor air quality, resulting in
coughing and wheezing and long-term increases in the
severity of asthma in communities of color. Currently, Black
Americans experience an asthma death rate 172% higher
than Whites and are hospitalized for asthma at three times
the rate of Whites (Wilson et al., 2012). Low-income com-
munities and communities of color continue to experience a
greater burden in relation to environmental pollutants and
air quality.
U.S. ENVIRONMENTAL LEGISLATION AND
REGULATION
Historically, environmental policy was considered a biparti-
san issue. Presidents and legislators from both major politi-
cal parties in the U.S. established laws and regulations during
the 1970s to reduce pollution and protect the environment.
In early 1970, President Richard Nixon sent Congress a

detailed, far-reaching proposal for protecting the environ-
ment that asked Congress to allocate $4 billion to improve
water treatment facilities in the United States and sought leg-
islation to end the dumping of waste into the Great Lakes
(EPA, 2021a). In addition, the proposed legislation called
for Congress to set water and air quality standards, increase
research funding focused on reducing automobile waste
emissions, tax lead additives in gasoline, and mandate
cleanup of federal facilities that polluted air or water sources.
Nixon also established an advisory council to provide rec-
ommendations for organizing federal government programs
to reduce pollution. The council recommended the creation
of a federal agency under which many of the federal govern-
ment’s environmental responsibilities should be consoli-
dated. This agency would become the Environmental
Protection Agency (EPA). Congress approved and enacted
Nixon’s proposal in 1970, and on December 4, 1970, Wil-
liam Ruckelshaus was sworn in as the first Director of the
EPA (EPA, 2021a).
In 1976, Congress passed the Toxic Substances Control Act
(TSCA) of 1976 (Tracking the U.S. Congress, 1976), which
provided the EPA with authority to require various report-
ing and record-keeping, issue permits, inspect chemical facil-
ities, and place restrictions on or ban chemical substances
determined to cause potential harm to public health or the
environment (EPA, 2021b). Specifically, the law directed
Congress to phase out the use of PCBs. TSCA excludes
EPA oversight of toxins in food, drugs, pesticides, and cos-
metics. These substances are controlled by the Food and
Drug Administration (FDA). TSCA has been amended
numerous times since 1976 to expand and strengthen EPA
control over toxic substances and provide the EPA with
authority to specifically control the use, manufacturing,
processing, distribution, and disposal of a list of six chemical
substances determined to be significantly detrimental to
human health: lead, asbestos, PCBs, radon, mercury, and
formaldehyde (EPA, 2021b).
Six federal departments or agencies currently hold juris-
diction over environmental regulation in the United States:
the EPA, FDA, U.S. Department of Agriculture (USDA),
Department of Energy; National Oceanic and Atmospheric
Administration; and Department of the Interior, which
includes the United States. Fish and wildlife services and the
National Park Service (Beaumont, 2017). Of these, the
EPA, FDA, and USDA are primarily tasked with safeguard-
ing U.S. air, water, and food from pollution and toxic sub-
stances.
Air Quality
Although Congress passed legislation regarding auto exhaust
and air pollution before 1970, the Clean Air Act of 1970
marked a significant shift in considering air pollution from
not only a regional problem but a national problem warrant-
ing a comprehensive national plan for regulation. The law
established the basic structure and key provisions for moni-
toring and improving air quality in the United States (EPA,
2017a) that remains intact today. The law targeted the
protection of the public’s health and welfare from air pollu-
tion caused by a variety of sources. A key provision in the
Act directed the EPA to set air quality standards and estab-
lish a critical list of air pollutants to be monitored for
national air quality. Congress made major revisions in the
Clean Air Act (U.S. Government Publishing Office, 1970) in
1977 and 1990 to improve and strengthen the law’s effec-
tiveness and address emerging air pollution problems such
as depletion of the earth’s stratospheric ozone layer and acid
rain (EPA, 2017a).
Maintaining the nation’s air quality relies on federal, state,
and local efforts mandated by the Clean Air Act (U.S. Gov-
ernment Publishing Office, 1970). The EPA’s Office of Air
Quality Planning and Standards sets national ambient air
quality standards for pollutants harmful to humans emitted
from factories, automobiles, and other sources and works
with states to ensure that standards are met (EPA, 2016). In
addition, the EPA monitors a list of six critical air pollutants
that affect air quality and have been determined to cause
harm to humans: particulate matter, ozone, carbon monox-
ide, lead, sulfur dioxide, and nitrogen dioxide (EPA, 2016).
The EPA works with states to identify areas that do not
comply with standards and requires states with nonattain-
ment sites to develop and submit plans to improve the air in
those areas.
Water Quality
In 1969, a federal report found that three out of four people
in the United States relied on public water supply systems
for their drinking water, but half of these systems were
found to be substandard (EPA, 1972). The country’s rivers
and waterways were becoming increasingly polluted. To
address these concerns in 1972, Congress significantly
amended and expanded the Federal Water Pollution Control
Act of 1948 to create what later became known as the Clean
Water Act of 1972 (U.S. Government Publishing Office,
1972). The law mandated the EPA to “restore and maintain
the chemical, physical, and biological integrity of the nation’s
waters” (EPA, 1972, para. 7). The law established two goals:
(1) to eliminate the discharge of pollutants into U.S. naviga-
ble waters; and (2) to establish a water quality safe for wild-
life, shellfish, fish, and people navigating or recreating in
water. In addition, provisions in the Clean Water Act of
1972 (U.S. Government Publishing Office, 1972) required
states to adhere to EPA water quality standards and made it
unlawful to discharge any pollutant into federal waters with-
out a permit (EPA, 1972).
Maintaining safe waterways and quality drinking water
requires collaboration between the EPA and state and local
municipalities. As designated in the Navigable Waters Protection
Rule, the EPA maintains federal regulatory authority for four
categories of water: territorial seas and traditional navigable
waters; tributaries to those waters; designated lakes, ponds,
and impoundments; and wetlands connected to jurisdic-
tional waters (EPA, 2020b). The agency is responsible for
monitoring and controlling pollutant discharge through the

issuance of discharge permits with the ultimate goal of even-
tually eliminating the discharge of pollutants into U.S.
waters.
The EPA also sets legal limits and water-testing schedules
and methods for over 90 contaminants in drinking water
(EPA, 2017b). Contaminants monitored include microor-
ganisms such as Escherichia coli and cryptosporidium, disin-
fectants, inorganic chemicals (e.g., arsenic, asbestos, lead,
mercury, etc.), organic chemicals (e.g., benzene and carbon
tetrachloride), and radionuclides such as radium and ura-
nium. Although the EPA sets standards, local cities and
municipalities determine water sources, the addition of
decontaminants like chlorine, and other additives such as
fluoride. The complexity of maintaining drinking water qual-
ity can be seen in the recent example of the Flint, MI water
crisis, which began in 2013 when the city deficit forced the
appointment of an emergency manager by the Governor to
cut costs. Although the EPA sets the allowable legal limits
for lead in water, local municipalities and states are responsi-
ble for monitoring and testing compliance with the set
standards. The decision by the state emergency manager to
save money by drawing water directly from the Flint River
instead of piping in water from Detroit resulted in the river’s
highly corrosive water contaminating the city’s drinking
water. Lead leached out from aging pipes into thousands of
homes resulting in many of Flint’s children being severely
lead-poisoned, primarily affecting most Black and low-
income residents living in the community (Denchak, 2018).
Food Quality
Three federal agencies share primary responsibility for main-
taining food safety in the United States, including the EPA,
FDA, and the Food Safety and Inspection Service (FSIS;
Food Safety and Inspection Service, n.d.) of the USDA. The
EPA plays a smaller role in food safety than the other two
agencies because its primary responsibility is to license pesti-
cide products used in the United States and set tolerances
for the maximum allowable pesticide residuals in food prod-
ucts and animal feed (EPA, 2020a). EPA programs also con-
tribute to food safety by ensuring air and water quality to
prevent food contamination by toxins. Although the Centers
for Disease Control and Prevention does not have a direct
role in protecting food safety, it plays a critical role in provid-
ing epidemiological monitoring and tracking of foodborne
illness outbreaks in the United States.
In 2010, Congress passed the Food Safety Modernization Act
(FSMA; Food and Drug Administration, 2021). The FSMA
advanced the FDA’s food safety program from reacting to
outbreaks of foodborne illness to the prevention of food-
borne illness. The law provided the FDA with increased abil-
ity to enhance food inspection, enforce compliance with
food safety standards, and require imported foods to meet
the same food safety standards as required for domestic
foods. The FSMA ushered in mandatory produce safety
standards and preventive controls for food processing facili-
ties and authorized the FDA to issue regulations to prevent
intentional contamination or adulteration of food (EPA,
2018). The law provides the FDA with the ability to issue
mandatory recalls of unsafe food and enhance systems to
trace sources of domestic and imported foods deemed
unsafe. The FDA is responsible for ensuring food safety for
all foods except for meat, poultry, and eggs, which fall under
the jurisdiction of the FSIS of the USDA. The FSIS con-
ducts regular inspections of meat, egg, and poultry process-
ing plants and sets standards to prevent microorganism or
toxin contamination of meat, poultry, or eggs.
RECENT ROLLBACKS OF ENVIRONMENTAL
LAWS AND REGULATIONS
Despite continued recommendations from climatologists
and environmentalists urging federal action to advance fed-
eral policies to protect the environment and public health,
Congress and presidential administrations have made few
improvements in environmental policy over the past decade.
Because of this legislative inaction, recent improvements
and updates to environmental regulatory policies rely on
executive orders vulnerable to oscillations between adminis-
trations. For example, in early 2016, under the Obama
administration, the EPA issued the first rule to target meth-
ane emissions arising from fracking to obtain oil and natural
gas (Environmental Energy Law Program [EELP],
2021d). In April 2017, the EPA under the Trump adminis-
tration, eliminated the standards for emissions of methane
from oil and gas industry facilities and revoked a prior
request for state plans to reduce volatile organic compounds
(Vizcarra, 2020).
From 2017 through 2020, the administration enacted
150 executive actions or regulations to weaken or overturn
prior regulations aimed at curbing air pollution (64), ensur-
ing safety from chemical toxins (14), protecting public lands
from drilling, or extracting fossil fuels (61), ensuring use of
scientific data in developing protections for public health
(1), ensuring the protection of water and wetlands (15) and
protecting endangered wildlife (30; Eilperin, Dennis,
Muyskens, 2021). A number of environmental deregulations
occurring between 2017 and 2020 posed a particular con-
cern for pregnant women, infants, and children as they
weakened policies related to water and air quality or emis-
sions of harmful toxins into the atmosphere.
As mandated in the Clean Air Act (U.S. Government
Publishing Office, 1970), the EPA is required to set national
ambient air quality standards (NAAQS) for six pollutants
determined to be harmful to humans. The Clean Air Act (
U.S. Government Publishing Office, 1970) requires the EPA
to update and revise standards in accordance with current
science on the basis of the sole criterion of public health and
welfare protection. The EPA must also review NAAQS
standards every 5 years (EELP, 2021b). In late 2020, the
EPA issued two final rules declining to update NAAQS
standards for particulate matter (final rule issued December
7, 2020) and ozone (final rule issued December 23, 2020),
leaving outdated standards in place. Per executive order
issued in late January, the current administration has ordered

the EPA to review NAAQS standards for these two sub-
stances.
Because of concern for the vulnerability of some water-
ways and wetlands to pollution from industrial facilities and
concentrated animal feeding operations, the EPA and the
Army Corps of Engineers under the Obama administration
expanded the number of streams and wetlands designated
for federal protection under the Clean Water Act (U.S. Gov-
ernment Publishing Office, 1972). Under the Trump admin-
istration, the EPA and Army Corps of Engineers revised the
rules under the Clean Water Act (U.S. Government Publish-
ing Office, 1972) and narrowed the protected designation of
wetlands and streams, and reduce federal authority over a
significant number of wetlands. Environmentalists worry
that these changes will pose a risk for some wetlands
because of industrial and feedlot pollution and will open
these areas to development that will weaken the capability to
control flooding (EELP, 2021e).
On June 19, 2019, the EPA replaced the Clean Power
Plan (CPP) rule by publishing the Affordable Clean Energy
rule (Nuccitelli, 2019). Although the replacement rule still
requires EPA regulation of carbon pollution, it mandates the
least amount of possible change from the power utility
industry, which will result in a negligible reduction in carbon
emissions. The DC circuit court struck down the Affordable
Clean Energy rule on January 19, 2021, but did not reinstate
the CPP, which means that states are not required to submit
plans to monitor carbon pollution as normally required by
the CPP.
During the Obama administration, environmental advo-
cacy groups petitioned the court to ban the use of chlorpyri-
fos, a pesticide that is considered highly neurotoxic,
especially for fetuses, infants, and young children. The Ninth
Circuit court ordered the EPA to finalize a rule to ban chlor-
pyrifos. In April 2017, the EPA denied the advocacy groups’
petition. On December 3, 2020, the EPA proposed an
interim rule to change the label for chlorpyrifos to restrict
some of its usages (EELP, 2021c). The Biden administration
extended the public comment period for this proposed
interim rule through March 7, 2021. A number of states
have enacted laws to either ban or phase out the use of this
pesticide, and the company that manufactures chlorpyrifos
announced plans in 2020 to phase out its production (Nee-
ley, 2020).
To reduce power plant emission of mercury and other
toxic substances, the Clean Air Act (U.S. Government Pub-
lishing Office, 1970) requires the EPA to set mercury and
air toxic stands (MATS; EELP, 2021a). Mercury is a potent
neurotoxin that becomes deposited in soil and water and
contaminates the food chain, which poses serious harm for
pregnant women and very young children. As part of the
process of issuing MATS, the EPA is required to establish
that the limits set are “appropriate and necessary.” Under
the Obama administration, the EPA issued the MATS rule
on February 16, 2012. Some coal power plant states and
industry groups legally challenged the rule. The DC circuit
court directed the EPA to re-review the 2012 rule to
determine if the MATS were “appropriate and necessary.”
Following the EPA’s determination that they were necessary,
those opposed to the rule once again challenged the rule.
After numerous attempts to undergo new rule proposals
and public comment periods, the EPA withdrew the findings
of “appropriate and necessary” on April 16, 2020, which
ultimately weakened the MATs rule and air quality standards
(EELP, 2021a).
Since January 20, 2021, the current administration has
overturned 29 policies, including an executive order issued
in late January, which ordered the EPA to review NAAQS
standards for particulate matter and ozone. The current
administration is also working on policy remedies to
strengthen or reinstate weakened or overturned regulations.
Enacting environmental policy via executive branch agency
rule changes and presidential executive orders instead of
Congressional statutory action leads to instability and politi-
cization of environmental policies as presidential administra-
tions change. If the United States is to move forward with
stable, evidence-based environmental policies, Congress
must take action to enact laws to protect the environment
and address climate change.
ENVIRONMENTAL HEALTH ADVOCACY
Effective environmental advocacy requires knowledge of the
historical development of environmental policy and current
regulatory and statutory mechanisms to be strategically tar-
geted. It also requires understanding that policymaking
occurs within the state and the federal governments at legis-
lative and executive branch levels. Ultimately, the judicial
branch plays an important role in determining that laws are
constitutional and regulations comply with the letter and
spirit of enacted laws.
Tracking environmental legislation before Congress can
be accomplished using the http://www.congress.gov Web
site and searching by a variety of search words such as “envi-
ronment,” “lead,” “mercury,” “poly- and perfluoroalkyl sub-
stances,” “toxins,” “air quality,” “water quality,” and “food
contamination.” Advocates that register at the site can
receive tracking information about key pieces of legislation
and important dates in the legislative process. The three
most strategic times to contact Congressional Representa-
tives or Senators about a specific bill are (1) when it has first
been introduced by a sponsor and cosponsors and needs to
have additional cosponsors sign onto the bill, (2) immedi-
ately before the bill’s hearings in House or Senate Committee
hearings, and (3) before a vote for the bill on the floor of the
House or Senate. The legislation search process on the Web
sites in many state legislatures is quite similar to the http://
www.gov/ search site. The best time to contact state legisla-
tors is before committee hearings and floor votes. The best
methods for communicating with members of Congress or
state legislators include sending e-mail messages or directly
phoning the legislator’s office as a constituent.
Once a piece of legislation becomes law, it is assigned to
an executive branch department or agency (e.g., EPA) or
several agencies deemed appropriate for establishing the

rules to operationalizing the law. Agencies must publish
every proposed rule on the Federal Register and assign a
period for public comment, often 60 days (Federal Register,
n.d.). Environmental and child health advocates can pro-
mote proenvironment and child health policies using the Fed-
eral Register system to identify proposed rules and submit
comments. During this comment period, pediatric providers
can best influence the adoption or elimination of a rule by
submitting a written comment. Those expert comments and
recommendations are taken into consideration before pub-
lishing the final rule. The Federal Register (federalregister.gov)
Web site has a robust tracking system and allows advocates
to search proposed rules in many categories.
ADVOCACY AND CLINICAL STRATEGIES FOR
PEDIATRIC HEALTH CARE PROVIDERS
Pediatric advanced practice registered nurses, pediatricians,
and others who care for children need to raise their expert
voices to advocate for environmental laws and regulations
to protect infants, children, and adolescents from harms
caused by pollution, exposures to toxins, climate change,
and environmental degradation. Pediatric advanced practice
registered nurses and pediatric health care providers have an
important role in educating parents and guardians about
potential risks and preventive strategies to protect children
from immediate and future environmental threats. Every ini-
tial primary well-child visit should include an overall assess-
ment of the child and family’s indoor and outdoor
environments, including information about the home, neigh-
borhood and its proximity to environmental hazards, and
daycare and/or school settings. Home environment assess-
ment should include information about parents’ occupations
and any concerns about contaminants being brought into
the home from the workplace and information about the
use of tobacco products, insecticides, or other potentially
toxic agents inside the home. Outdoor environmental
threats need to be considered, such as fertilizers, herbicides,
and pesticides in areas where children may play. Families
should be encouraged to seek water quality assessments for
home wells or review city water quality data using a munici-
pal water supply. Schools and daycare centers often will pro-
vide water quality information on request. Primary care
providers can familiarize families with Web sites that provide
important safety information about local air quality, heat
index warnings, and food sources such as fruits, vegetables,
and fish. Pediatric care providers are in the best position to
continually assess environmental risks and hazards on an
ongoing basis and provide developmentally appropriate
anticipatory environmental guidance to families and care-
givers.
Two additional ways pediatric health care providers can
influence environmental and child health policy is using their
expertise to educate the public about environmental threats
to child health and joining professional organizations or coa-
litions that advocate for child and environmental health,
such as the National Association of Pediatric Nurse Practi-
tioners, the American Association of Pediatrics, the
Planetary Health Alliance, and the Alliance of Nurses for a
Healthy Environment. These organizations and coalitions
provide education about environmental health issues and
equip members with important environmental health policy
advocacy information.
Conclusions
Child health is inextricably linked to planetary health. Those
committed to caring for the health and wellbeing of children
can no longer sit on the sidelines and ignore the urgent, exis-
tential threats environmental degradation, pollution, and cli-
mate change pose to the world’s children. The time for
advocacy is now. Environmental and child health advocates
must promote public health policies that place child health
at the center of the decision-making process to foster the
health and wellbeing of the next generation of Americans.
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